Journal of Bronchology & Interventional Pulmonology最新文献

Background: Peripheral pulmonary lesions (PPLs) are frequently identified and require diagnostic sampling. Diagnostic yield of radial endobronchial ultrasound (rEBUS) guided bronchoscopic biopsies is suboptimal, despite ultrasound confirmation of navigation success. Pairing ultrathin bronchoscopy and peripheral transbronchial needle aspiration (pTBNA) may improve yield.

Methods: We prospectively recruited consecutive patients undergoing Olympus MP190F ultrathin bronchoscopy with rEBUS-guided sampling of PPLs. Cases were randomized to pTBNA (Olympus Periview FLEX) either before or after the usual transbronchial forceps biopsy (TBLBx) and brush. Diagnostic yield from cytology or histopathology, clinical outcomes to a minimum 24 months follow-up and complications were recorded.

Results: One hundred one sampled lesions were included (pTBNA first 61, pTBNA last 40). Overall diagnostic yield was 66.3%, with no significant difference between groups (64% vs. 70% P=0.528) or prespecified subgroups according to sampling order. Seventy lesions had an end diagnosis of malignancy, of which 50 were correctly diagnosed (71.4%). TBLBx (49/96, 49%) and pTBNA (48/101, 47.5%) had the highest individual positive yield. For 12 (11.9%) participants, pTBNA was the only positive sample. Lesions <20 mm and those with eccentric rEBUS image seemed to benefit most from this approach. Rapid on-site cytologic examination (ROSE) was associated with both positive procedural diagnosis (P=0.019) and pTBNA-positive samples (P=0.004). Pneumothorax occurred in 4% and moderate bleeding in 5%. Thirteen percent had an unplanned admission within 1 month of bronchoscopy.

Conclusion: Adding pTBNA to conventional sampling through an ultrathin bronchoscope guided by rEBUS, improved diagnostic yield (11.9% additional diagnoses). The sampling sequence did not affect the yield of pTBNA.

Background: In 2020, a mandatory, nationwide 1-day bronchoscopy simulation-based training (SBT) course was implemented for novice pulmonology residents in the Netherlands. This pretest-posttest study was the first to evaluate the effectiveness of such a nationwide course in improving residents' simulated basic bronchoscopy skills.

Methods: After passing a theoretical test, residents followed a 1-day SBT course, available in 7 centers, where they practiced their bronchoscopy skills step-by-step on a virtual reality simulator under pulmonologist supervision. Residents practiced scope handling efficiency (task 1) and navigational skills combined with lung anatomy knowledge (task 2). Task 1 outcome measures were navigational skill simulator metrics: percentage of time at mid-lumen, percentage of time with scope-wall contact, procedure time (PT), number of wall contacts and number of wall contacts per minute of PT. Task 2 outcome measures were PT, observational assessment scores of a validated tool with a 5-point scale (1 representing the worst and 5 the best competence) and blinded dexterity assessments.

Results: The study included 100 residents. All outcome measures of task 1 improved significantly (P<0.001), except for the number of wall contacts per minute of PT (4.3 [IQR 3.0 to 6.2] pre vs. 3.5 [IQR 2.6 to 5.3] post, P=0.07). For task 2, PT was reduced by 54% (10.3±2.7 minutes pre vs. 4.7±0.9 minutes post, P<0.001) with an improvement in overall-competence scores (2.0 [IQR 1.0 to 2.0] pre vs. 4.0 [IQR 4.0 to 5.0] post, P<0.001) and all dexterity parameters (P<0.001).

Conclusion: Nationwide implementation of a SBT course led to rapid improvement of residents' basic bronchoscopy skills while halving PT.

Background: Pleural effusions remain a common postoperative complication following lung transplantation, occurring in 10% to 26% of cases. We aimed to explore potential clinical or radiographic features associated with clinically significant post-lung transplant pleural effusions requiring repeat interventions for their management.

Methods: Lung transplantation recipients who underwent thoracentesis at our institution between June 2012 and October 2022 were reviewed. In total, 77 patients were included. Data were collected via the electronic health record and adjudicated through direct chart review. Patients were stratified by the need for a single thoracentesis (control group) or additional interventions, including serial thoracentesis, pigtail placement, and surgery (composite group). The computed tomography (CT) of the chest before the first thoracentesis was reviewed by a thoracic radiologist who was blinded to patient outcome.

Results: Single thoracentesis was used to manage 25 (32.5%) patients, 4 (5.2%) required multiple thoracenteses, 42 (54.5%) required a pigtail catheter, and 6 (7.8%) required decortication for definitive management. In the composite group compared with the control group, who were managed by a single thoracentesis, there was an increased incidence of loculations (36.8% vs. 8%, P=0.01), rounded atelectasis (22.8% vs. 4%, P=0.05), and larger effusion size (P=0.01). The composite group had higher pleural fluid eosinophils (0.33% vs. 0% in control, P = <0.01) and monocytes (14.8% vs. 7.3%, P=0.04) levels.

Conclusion: Baseline imaging, such as larger effusion size, loculations and rounded atelectasis, and pleural fluid cell profile with increased eosinophils and monocytes, can potentially identify clinically significant and refractory pleural effusions.

Background: Open window thoracostomy (OTW) is the standard of care for debilitated patients with chronic pleural infection and nonexpandable lungs (NEL) who are not candidates for major surgical intervention. Tunneled pleural catheters (TPC) offer tremendous treatment potential in this setting based on their efficacy in malignant pleural effusion and NEL. We aim to assess the efficacy, safety, and health care utilization of TPC in this setting.

Methods: We retrospectively evaluated patients who underwent TPC procedures for the long-term management of chronic pleural infection and NEL who were not candidates for major surgical intervention. Clinically, complete treatment success was defined as fever abatement, normalization of white cell count, and stoppage of antimicrobial therapy without requiring surgical intervention. It is deemed a partial success if chronic antimicrobial suppression is still needed.

Results: There were 20 patients who had TPC placed for chronic pleural infection with NEL. Clinical and partial treatment success was achieved in 9/17 and 8/17 patients, respectively, excluding 3 patients who were placed on comfort measures only. The median change in pleural volume was -218 mL. The median length of stay after TPC placement was 4.5 days. TPC was removed in 8 patients due to successful obliteration of pleural space in a median duration of 46.5 days. Four patients passed away with TPCs in place, 7 retained TPCs at the last health care system contact, and 1 patient had OTW due to TPC failure.

Conclusion: This exploratory study suggests that TPC is an effective and safe intervention for the management of patients with chronic pleural infection and NEL lung who are not candidates for surgical intervention.

Background: Percutaneous dilational tracheostomy (PDT) is commonly performed by a broad spectrum of practitioners. Aside from relative contraindications such as morbid obesity, coagulopathy, and complex airway anatomy, it is preferred over surgical tracheostomy in the critically ill. Rigid bronchoscopy-guided (RBG) PDT provides a secure airway, allows for unobstructed ventilation, protects the posterior membrane from puncture, and increases suction capacity.

Methods: This is a retrospective case series of patients who underwent RBG-PDT from 2008 to 2023 at Beth Israel Deaconess Medical Center. Electronic medical records were reviewed for preprocedural demographic data, procedural events, and postprocedural outcomes.

Results: A total of 104 patients underwent RBG-PDT over a 15-year period. Median patient age was 61.95 (95% CI: 59.00-64.90), median BMI was 30.25 kg/m2 (IQR, 23.6 to 37.2) with 41.9% (32.5% to 51.3%) of patients included having a BMI over 30 kg/m2. PDT placement occurred in a mean of 13.7 days after intubation, with 70% due to prolonged mechanical ventilation resulting from ongoing respiratory failure. In all, 51.0% of patients had at least one increased bleeding risk factor, with an increased aPTT >36 seconds being the most common (36.5%). In all, 26.9% of patients underwent tracheostomy with ongoing therapeutic anticoagulation with heparin. In total, 60.6% of patients received concomitant percutaneous endoscopic gastrostomy (PEG) tube placement. No cases of pneumothorax or loss of the airway at the time of exchange of the endotracheal tube for rigid tracheoscopy were reported.

Conclusion: RBG-PDT is a safe and effective procedure extending the patient population appropriate for PDT when performed by an experienced Interventional Pulmonology team.

Background: Mucus plugging is a common complication of airway stenting. There is no data or guidance on the best airway hygiene regimen and consequently wide practice variation exists.

Methods: This single-center, nonblinded, randomized, pilot study aims to evaluate the effectiveness and safety of nebulized 3% saline (3%S) versus normal saline (NS) in reducing the incidence of mucus plugging in adult patients that undergo central airway stent placement. Patients were enrolled immediately after stent placement and randomized to nebulized 3%S or NS (3 mL) 3 times a day. Patients were scheduled for surveillance bronchoscopy in 4 to 6 weeks. Unscheduled bronchoscopies due to symptomatic mucus plugging were recorded.

Results: From December 2022 to March 2024, 37 patients were screened, and 35 were enrolled. Four in the 3%S and 8 in the NS group did not undergo a surveillance bronchoscopy and were excluded from the final analysis. During surveillance bronchoscopy for the 3%S (n=13) and NS (n=10) groups, obstructive mucus plugging was noted in 7.7% versus 40%, granulation requiring intervention in 7.7% versus 10%, and >25% circumferential biofilm in 0% versus 30%, respectively. In the 3%S versus NS groups, 0% versus 20% of patients required an unscheduled bronchoscopy due to mucus plugging. There were no side effects reported with the daily use of 3%S or NS.

Conclusion: Nebulized 3%S is safe and may be equally or more effective than NS in preventing obstructive mucus plugging in patients who undergo airway stenting. A larger blinded randomized controlled trial is necessary to confirm this finding.

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has become an important tool in the diagnosis and staging of mediastinal lymph node lesions in lung cancer. Adequate sedation is an important part of the procedure as it provides patient comfort and potentially increases diagnostic yield. The sedation modality varies among centers and includes moderate sedation/conscious sedation, deep sedation, and general anesthesia. The object of this study will be the evaluation of patient's comfort and level of satisfaction with the involved health care providers (bronchoscopist and anesthesiologist) of remifentanil administration in target-controlled infusion (TCI) for conscious sedation in patients undergoing EBUS‑TBNA, with a prospective randomized study design versus the of standard sedation protocol with midazolam and/or fentanest and/or propofol.

Methods: This study was carried out at the "Campus Biomedico di Roma" University Hospital between September 2021 and November 2021, with a total number of 30 patients enrolled who met the eligibility criteria, randomly divided into 2 groups: group 1 "REMIFENTANIL TCI" (experimental group) where the patients performed the EBUS-TBNA procedure under conscious sedation with infusion of remifentanil TCI with a target between 3 ng/mL and 6 ng/mL and group 2 "STANDARD" (control group) with patients undergoing conscious sedation with the association of midazolam and/or fentanest and/or propofol in refracted boluses based on clinical needs. Complications, safety, and level of satisfaction of the operator, the anesthesiologist, and the patient were evaluated.

Results: The results show that sedation with remifentanil in TCI can improve the comfort level of patients, reducing the risks associated with the procedure (lower frequency of oversedations and hypotension), allowing for greater intraprocedural safety. Furthermore, the level of satisfaction of the anesthesiologist and that of the operator appears to be significantly higher in the Remifentanil group.

Conclusion: The execution of a mild to moderate sedation with Remifentanil in TCI in patients undergoing EBUS is safe, tolerated, and allows to obtain greater intraprocedural comfort. Further studies and larger and more representative samples are obviously needed to confirm and strengthen the validity of a remifentanil TCI-based sedation in endoscopic diagnostics.

Background: Dexmedetomidine has acceptable clinical utility for inducing sedation during flexible bronchoscopy. Reducing its dose may not only ameliorate its cardiovascular side effects, but also maintain its clinical usefulness.

Methods: Patients between 18 and 65 years were randomized to either dexmedetomidine (0.75 µg/kg) or the midazolam-fentanyl group (0.035 mg/kg midazolam and 25 mcg fentanyl). The primary outcome measure was the composite score. Other parameters noted were: oxygen saturation, hemodynamic variables, Modified Ramsay Sedation Score, Numerical Rating Scale (NRS) for pain intensity and distress, Visual Analog Scale score for cough, rescue medication doses, ease of doing bronchoscopy, and patient response 24 hours after bronchoscopy.

Results: In each arm, 31 patients were enrolled. The composite score at the nasopharynx was in the ideal category in 26 patients in dexmedetomidine and 21 in the midazolam-fentanyl group (P=0.007). At the tracheal level, the corresponding values were 24 and 16 (P=0.056). There was no significant difference between the 2 groups regarding the secondary outcome measures except hemodynamic parameters. The mean heart rate in the dexmedetomidine and midazolam-fentanyl groups, respectively, was as follows: at 10 minutes after start of FB (90.10±14.575, 104.35±18.48; P=0.001), at the end of FB (98.39±18.70, 105.94±17.45; P=0.016), and at 10 minutes after end of FB (89.84±12.02, 93.90±13.74; P=0.022). No patient developed bradycardia. Two patients (P=0.491) in the dexmedetomidine group developed hypotension.

Conclusion: Low-dose dexmedetomidine (0.75 μg/kg single dose) appears to lead to a better composite score compared with the midazolam-fentanyl combination.